Expert: Dr. J. Shawn Leatherman - 4/4/2007

Question
I was injuried in Iraq in Aug. 2004.  I dislocated my SI Joint, buldged 2 disc's, messed up 3 facets, and have an annualar tear.  All these injuries are located at L-3 thru S-1.  I continued to walk around for 5 1/2 months before the SI Joint was pushed back in place.  This lasted about 2 weeks before it started coming back out.  I have asked pain managemant doctors, physical therapist's, ortho doctors to push the SI Joint back in place but they do not believe the SI Joint can be pushed back in place.  It has been 3 years since I injuried it.  I cannot get any pain relief even though my pain management doctors burned the facet nerves located at L-3,L-4,L-5, and S-1.  This has helped my back pain in that area but my hip still causes me serious pain.  Also I'm having problems with my left hip now.  I had my doctor to let me use a cane because it slightly helps the left hip.  Is there any thing I can do or is there any way of treating this problem.  Or do I just let the joint wear out and have it bolted together.  

Answer
Dear Jeffery,

Sorry to hear of all the controversy concerning your SI and disk injuries.  Hopefully I will be able to clear some things up.

Concerning your worries, I have a few points I would like to touch on. I want to clarify any misconceptions you have. Your doctors are correct that you cannot just push the Si joint back into place, and it doesn't just pop out of joint either.  This is an anatomical impossibility without a severe and purposeful excision of the ligaments that surround and encompass the joint space.  that being said, you are correct in the notion that when the Si joint is working and moving properly that your pain abates, as your problem is likely more of a fixation of the joint.  

The hip symptoms you have described can come from sacroiliac dysfunction, because the sacroiliac joint has pain patterns that encompass the entire leg depending on the dysfunction of the joint, the ligamentous complex and associated muscles. It gets its nerve supply from L3 to the S2 nerve roots, but this would not be like the nerve generated pain that you were treated for with the nerve ablation by pain management.  There is also a type of pain called sclerotogenous pain which does not generate from the nerves, but rather from the ligament, cartilage and disk.  This pain is diffuse and covers broad areas.

Moving on, as you may already know, the majority of the stability of the SI joint comes from the ligaments.  They are probably the strongest in the body and a ligament serves to limit joint movement.  The actual movement that occurs within the SI joint is very small.  Most of the research I have read indicated that the SI joint moves only 1-3mm.  For many years it was thought that the joint did not move at all, but it is a true synovial joint and has movement, therefore it can be manipulated.

Concerning manipulation or adjustment of the joint, it is common to use a side posture adjustment to address the joint. Technically you are moving the joint with manipulation, but again we are talking about very slight movement.  The key to chiropractic manipulation is not the actual movement of the joint, rather the quick release of pressure within the synovial fluid of the joint...that is what makes the popping sound.  It is a release of gasses that happens quickly and escapes the synovial capsule, just like when you open a champagne bottle quickly.

When this happens joint receptors are firing signals to the brain.  These are called mechanoreceptors because they respond to movement and mechanical stimuli.  There are also proprioceptors which transmit information to the brain about body position and awareness.  Both of these transmitters send information to the spinal cord and brain which will inhibit the pain receptors in the joint which are called nociceptors.  It is a neurological and physiological relationship reducing inflammation and pain transmission.  That is why you felt the pain relief for those two weeks, because the joint was working properly and the mechanoreceptors were being stimulated to reduce pain signals.

Concerning your specific treatment, I would seek the care of a competent chiropractic physician.  you do not need to worry about creating excessive motion, the ligaments are too strong for that and all chiropractic techniques were designed and are taught in a manner not to take the joint into any pathological range of motions.  In other words an adjustment happens in the normal physiological range of motion of the joint.

There are other ways to adjust the SI joint however without as much of a stretch to your torso and the lower lumbar and pelvic musculature.  The doctor could use a drop table adjustment where you lay on your stomach, or your back.  He could also use an instrument to vibrate the joint space as well as some "PNF" stretching in the low back.  He could also elect to adjust the sacrum to the pelvis instead of the pelvis to the sacrum which would mean a different hand placement for the doctor on your body.  All of these things will accomplish the same task, but have different effects depending on the patient's general condition.  These are points you should discuss with your chiropractor.  In addition you should be using ice to help reduce the inflammation around the joint.

Because of the anatomy of the SI joint and the functional limitations of movement, it is the obvious choice for treatment. In my clinical experience as well as a thorough scientific review of the work of Dr. Andry Vleeming, (SI joint research on anatomy and biomechanics), I would expect significant pain reduction with treatment.

I have performed thousands of SI joint manipulations/adjustments on my patients and results from SI pain after manipulation has been over 90% effective.  These are some of the easiest cases to get better in my experience.  Although your case is complicated, you should expect decent results.

Jeffery, I hope this sheds some light on your concerns regarding treatment and ongoing symptomatology.  If you have any further questions or comments please feel free to respond back.  In addition to read any of Dr. Andry Vleemings research, you can look it up on Medline or Pubmed through the internet.  In addition, I would highly recommend a book written by Dr. Stuart McGill as a reference for low back dysfunction called LOW BACK DISORDERS, Evidence-based prevention and rehabilitation.  I am sure you can find it at your local college library.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net